Christoph M. Heyer

Computed Tomography–Navigated Transthoracic Core Biopsy of Pulmonary Lesions: Which Factors Affect Diagnostic Yield and Complication Rates?

RATIONALE AND OBJECTIVES Only a few studies have systematically evaluated risk factors for pneumothorax and pulmonary hemorrhage in computed tomographically (CT)-guided transthoracic lung biopsy (TLB). We evaluated the diagnostic yield of CT-guided TLB and determined risk factors for pneumothorax and hemorrhage. METHODS One hundred seventy-two CT-guided TLBs were performed on 159 patients (mean age 66 +/- 11 years; 72% male) using a 16-gauge core biopsy needle. Lesion and patient characteristics, lung function analysis, CT signs of emphysema, histopathologic diagnoses, and complications were recorded. Statistical analysis was performed with multivariate regression analysis. RESULTS Histopathologic diagnosis was established in 153 cases (89%). Although lesion size was higher (47 +/- 29 vs. 43 +/- 35 mm, P = .191) and depth was lower (22 +/- 23 vs. 6 +/- 23 mm, P = .350) in procedures with histopathologic diagnosis, no parameter showed significant impact on diagnostic yield. Sensitivity and specificity for detection of malignancy were 93% and 100%, respectively, whereas positive and negative predictive values were 100% and 88%. Overall accuracy was 95%. Pneumothorax occurred in 45 procedures (26%). Hemorrhage was recorded in 17 procedures (10%). There was higher frequency of pneumothorax in smaller lesions (35 +/- 23 vs. 50 +/- 31 mm, P = .003; odds ratio = .96) and greater depth (29 +/- 29 vs. 20 +/- 19 mm, P = .05; odds ratio = 1.03). CT signs of emphysema revealed higher incidence of hemorrhage (35% vs. 23%; P = .04; odds ratio=41.03). Other parameters were nonsignificant. CONCLUSIONS The high diagnostic yield of CT-guided TLB was not affected by lesion characteristics or emphysema. Pneumothorax rate was influenced by lesion size and depth. Hemorrhage was associated with CT signs of emphysema.

Which labral lesion can be best reduced with external rotation of the shoulder after a first-time traumatic anterior shoulder dislocation?

IntroductionImmobilization in external rotation after a first-time traumatic anterior shoulder dislocation has been shown to improve the position of the labroligamentous lesion relative to the glenoid rim. The purpose of the present study was to evaluate the effect of the external rotation position of the shoulder on different types of labroligamentous lesions in patients with first-time traumatic anterior shoulder dislocation by using MRI.Patients and methodsWe performed a standardized MRI in internal and external rotation of the shoulder after initial reduction in 34 patients with a first-time traumatic anterior shoulder dislocation. Labroligamentous lesions were classified as Bankart, Perthes, or nonclassifiable. Four distinct grades were used to classify the amount of plastic deformation of the anterior labroligamentous structures. The position of the labrum was defined relative to the tip of the glenoid rim by measuring the dislocation and separation.ResultsIn all patients, dislocation and separation of the labrum relative to the rim of the glenoid were significantly improved in shoulders in the external rotation position compared to those in the internal rotation position. We observed 15 Bankart, 15 Perthes, and 4 non-classifiable lesions. No HAGL or GLAD lesions were found. Fourteen patients showed a plastic deformation grade I, 16 showed grade II, 3 showed grade III, and 1 showed grade IV. In regression analysis, the odds ratio was 1.100 for the type of lesion and 1.660 for the grade of plastic deformation. Perthes lesions (with an intact anterior scapular periosteum) and grade I plastic deformations showed the best labral reduction on the external rotation MRI.ConclusionPlacing the shoulder in external rotation after a first-time traumatic shoulder dislocation, significantly improves the position of the labroligamentous lesion on the glenoid rim. Perthes lesions that showed a low grade of plastic deformation displayed better reduction in external rotation and then compared to Bankart or other lesions that showed a high grade of plastic deformation. In conclusion, immobilization of the shoulder after a first-time traumatic shoulder dislocation is most effective in patients with Perthes lesions that show low grade plastic deformation.

CT Angiography in Suspected Pulmonary Embolism: Impact of Patient Characteristics and Different Venous Lines on Vessel Enhancement and Image Quality

OBJECTIVE The objective of our study was to compare image quality, patient characteristics, and different catheters in pulmonary CT angiography (CTA) performed with bolus tracking and z-axis automated tube current modulation (ATCM) in patients with suspected pulmonary embolism. SUBJECTS AND METHODS One hundred twenty-six patients were referred to undergo pulmonary CTA with bolus tracking and ATCM. Besides patient characteristics, the type, position, size, and side of venous catheters were documented. Pulmonary vessel enhancement and image noise were quantified; signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Subjective vessel contrast was assessed by two radiologists in consensus. RESULTS Patient age showed a moderate but significant positive correlation to vessel enhancement (r = 0.244, p = 0.006), CNR (r = 0.178, p = 0.046), and subjective image quality (r = 0.344, p < 0.001). Patient weight revealed a significant negative correlation to vessel enhancement (r = -0.496, p < 0.001), SNR (r = -0.446, p < 0.001), CNR (r = -0.425, p < 0.001), and subjective image quality (r = -0.422, p < 0.001). In univariate analysis, SNR and CNR were significantly higher in patients who received contrast medium through peripheral catheters (30 +/- 13 and 27 +/- 13, respectively) than in those in whom central catheters were used (22 +/- 8 and 19 +/- 7, p = 0.041 and p = 0.029, respectively). Neither patient sex nor catheter size, position, or side had any significant impact on image quality. CONCLUSION Patient age and weight showed significant impact on vascular attenuation and image quality in pulmonary CTA with bolus tracking and ATCM, whereas patient sex and different peripheral catheters did not significantly influence image parameters.

Metastasis to skeletal muscle from esophageal adenocarcinoma.

We report on a case of a 54-year-old man who was admitted to hospital with diffuse muscular pain and recurrent vomiting. Diagnosis of an adenocarcinoma of the esophagus was established by endosonography-guided biopsy. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed multiple nodular lesions within the skeletal musculature; CT-guided biopsy proved the metastatic origin of the primary tumor site. The report stresses the importance of CT and MRI in patients with proven or suspected metastases to skeletal muscle and provides a short overview of the literature.

Detection of a double right coronary artery with 16-row multidetector computed tomography.

We present the case of a 46-year-old male patient with known history of coronary artery disease and recurrent episodes of angina pectoris. Coronary angiography revealed two vessels originating from the right coronary sinus. However, a clear distinction between a double RCA and a high take off of a large right ventricular branch could not be made. Contrast-enhanced MDCT was performed on a 16-row scanner which clearly depicted cardiac anatomy and finally established the diagnosis of a double RCA. To our knowledge, this is the first report of a true double RCA diagnosed by MDCT.

Evaluation of chronic infectious interstitial pulmonary disease in children by low-dose CT-guided transthoracic lung biopsy.

BackgroundChildren with chronic infectious interstitial lung disease often have to undergo open lung biopsy to establish a final diagnosis. Open lung biopsy is an invasive procedure with major potential complications. Transthoracic lung biopsy (TLB) guided by computed tomography (CT) is a less-invasive well-established procedure in adults.ObjectiveDetailing the role of low-dose CT-guided TLB in the enhanced diagnosis of chronic lung diseases related to infection in children.Materials and methodsA group of 11 children (age 8 months to 16 years) underwent CT-guided TLB with a 20-gauge biopsy device. All investigations were done under general anaesthesia on a multidetector CT scanner (SOMATOM Volume Zoom, Siemens, Erlangen, Germany) using a low-dose protocol (single slices, 120 kV, 20 mAs). Specimens were processed by histopathological, bacteriological, and virological techniques.ResultsAll biopsies were performed without major complications; one child developed a small pneumothorax that resolved spontaneously. A diagnosis could be obtained in 10 of the 11 patients. Biopsy specimens revealed chronic interstitial alveolitis in ten patients. In five patients Chlamydia pneumoniae PCR was positive, in three Mycoplasma pneumoniae PCR was positive, and in two Cytomegalovirus PCR was positive. The average effective dose was 0.83 mSv.ConclusionLow-dose CT-guided TLB can be a helpful tool in investigating chronic infectious inflammatory processes in children with minimal radiation exposure. It should be considered prior to any open surgical procedure performed for biopsy alone. In our patient group no significant complication occurred. A disadvantage of the method is that it does not allow smaller airways and vessels to be assessed.

Effectiveness of CT-Guided Percutaneous Biopsies of the Spine : An Analysis of 202 Examinations

RATIONALE AND OBJECTIVES The study goal was to retrospectively evaluate the effectiveness of computed tomography (CT)-guided spinal biopsies. MATERIAL AND METHODS Two hundred two CT-guided vertebral biopsies performed between May 1999 and June 2004 in 187 patients were retrospectively analyzed. Patient characteristics (age, sex, antibiotic therapy), technical parameters (depth and number of biopsies, needle approach), lesion features (spinal level, osteolysis, fluid collections, soft tissue tumor), and complications were documented. Furthermore, histopathological and microbiological diagnoses were considered. RESULTS There were two focal hematomas in our study group (complication rate: 1%). Histopathological diagnosis was established in 74% of examinations with spondylitis (41% of cases) being most common. In spinal tumors (27% of cases), malignant lesions were found in 52 of 54 examinations (96%). Osteolysis was diagnosed in 98% of patients with spondylitis and in 87% of patients with tumors (P < .01). Spinal tumors were most commonly seen in the sacrum (53%, P < .001), whereas spondylitis typically occurred in the lumbar spine (55%, P = .001). Neither patient age nor sex, needle approach, needle depth, or vertebral abnormalities showed a significant impact on diagnostic accuracy. Microbiological tests were performed in 98 patients (49%); 62 of 98 patients (65%) received antibiotic therapy. In 12 of 62 patients (19%) with antibiotic therapy and in 9 of 36 patients (25%) without antibiotic treatment, microbiological tests were positive (P = .153). Staphylococcus aureus was found in 9 of 21 examinations (43%). CONCLUSIONS CT-guided vertebral biopsy is a safe and effective procedure to establish final diagnosis in spinal lesions of unclear origin. Patient characteristics, lesions features, and technical considerations did not influence sample quality. In spondylitis, which was commonly caused by Staphylococcus aureus, microbiological yield was low regardless of antibiotic therapy.

Effectiveness of CT-Guided Percutaneous Biopsies of the Spine: An Analysis of 202 Examinations1

RATIONALE AND OBJECTIVES The study goal was to retrospectively evaluate the effectiveness of computed tomography (CT)-guided spinal biopsies. MATERIAL AND METHODS Two hundred two CT-guided vertebral biopsies performed between May 1999 and June 2004 in 187 patients were retrospectively analyzed. Patient characteristics (age, sex, antibiotic therapy), technical parameters (depth and number of biopsies, needle approach), lesion features (spinal level, osteolysis, fluid collections, soft tissue tumor), and complications were documented. Furthermore, histopathological and microbiological diagnoses were considered. RESULTS There were two focal hematomas in our study group (complication rate: 1%). Histopathological diagnosis was established in 74% of examinations with spondylitis (41% of cases) being most common. In spinal tumors (27% of cases), malignant lesions were found in 52 of 54 examinations (96%). Osteolysis was diagnosed in 98% of patients with spondylitis and in 87% of patients with tumors (P < .01). Spinal tumors were most commonly seen in the sacrum (53%, P < .001), whereas spondylitis typically occurred in the lumbar spine (55%, P = .001). Neither patient age nor sex, needle approach, needle depth, or vertebral abnormalities showed a significant impact on diagnostic accuracy. Microbiological tests were performed in 98 patients (49%); 62 of 98 patients (65%) received antibiotic therapy. In 12 of 62 patients (19%) with antibiotic therapy and in 9 of 36 patients (25%) without antibiotic treatment, microbiological tests were positive (P = .153). Staphylococcus aureus was found in 9 of 21 examinations (43%). CONCLUSIONS CT-guided vertebral biopsy is a safe and effective procedure to establish final diagnosis in spinal lesions of unclear origin. Patient characteristics, lesions features, and technical considerations did not influence sample quality. In spondylitis, which was commonly caused by Staphylococcus aureus, microbiological yield was low regardless of antibiotic therapy.

Radiological Findings, Pulmonary Function and Dyspnea in Underground Coal Miners

Background: Respiratory disability induced by dust exposure in coal workers is assessed by pulmonary function tests and radiological evidence of pneumoconiosis. High-resolution computed tomography (HR-CT) improves the visibility of tissue changes, but the value of the findings for the clinical evaluation is controversial. Objectives: It was the aim of this study to evaluate the correlation between the International Labour Office (ILO) classification and the degree of emphysema in HR-CT with self-reported dyspnea and pulmonary function tests including diffusion capacity for CO (DL,CO). Methods: We investigated 87 coal miners (aged 67 ± 6 years), having worked underground for 26 ± 9 years, with pulmonary function tests and HR-CT. Univariate associations were tested with correlation coefficients, and multivariable analyses used a stepwise forward regression model. Results: No aspect of the ILO classification showed a univariate correlation with dyspnea or forced expiratory flow in 1 s (FEV1). Emphysema CT score was strongly associated with DL,CO (rs = –0.40; p < 0.001) and FEV1/maximal vital capacity (r = –0.38; p < 0.001) in univariate analysis, but not with the clinical grade of dyspnea (r = –0.14; p = 0.256). CT emphysema score but not ILO classification was associated with FEV1 in multivariable analyses (rs = –0.37; p < 0.001). Dyspnea was best approximated by DL,CO (r = –0.312; p = 0.008). Conclusion: The clinical grade of breathlessness was best approximated by DL,CO. HR-CT showed a good association with expiratory flow limitation. ILO classification of the chest radiograph may be a marker of exposure but conveys little information about the degree of respiratory impairment.

Efficacy of CT-guided biopsies of the spine in patients with spondylitis--an analysis of 164 procedures.

OBJECTIVE To evaluate efficacy of CT-guided spinal biopsy (CTSB) in patients with spondylitis considering patient characteristics, technical issues, antibiotic therapy, histopathological, and microbiological findings. MATERIALS AND METHODS All CTSB procedures performed between 1995 and 2009 in patients with proven spondylitis were re-evaluated. Patient sex and age, antibiotic treatment, biopsy approach, number of specimens, length of needle path, laboratory results (CRP, WBC), and histopathological/microbiological findings were documented and compared to the final diagnosis of spondylitis. Statistical analysis was performed using Chi-square test and Students t-test. The p-value was set to 5%. RESULTS 164 CTSB procedures were performed in 159 patients (mean age 65 years, 60% men) in which spondylitis was histopathologically verified in 95%. Neither patient sex nor age, positioning, localization of the spinal lesion, bioptic approach, number of specimens, or depth of the needle showed significant impact on the rate of positive histopathological findings. A causative germ was identified in 40/127 biopsies (32%) with Staphylococcus aureus being identified in 50%. Tuberculous spondylitis was diagnosed in ten cases (6%). CRP significantly correlated with bacterial growth (13.3±12.2 mg/dl versus 8.8±7.6 mg/dl; p=.015) whereas administration of antibiotics did not show any significant impact on bacterial growth (29% versus 36% in patients without antibiotics; p=0.428). Patients with histopathological signs of active spondylitis showed a significantly higher CRP (16.5±15.8 mg/dl versus 8.9±8.0 mg/dl, p<.001). Complication rate was 0.6% (one focal bleeding). CONCLUSION CTSB of the spine in suspected spondylitis is an effective and safe procedure for establishing final histopathological diagnosis. However, microbiological yield is low regardless of technical issues and antibiotic therapy. Other than CRP values, laboratory investigations added little useful information to diagnose infection in our study group. CRP values significantly correlated with bacterial growth and with histopathological signs of active spondylitis.